INDIANA UTILITY REUSABLE MASK REQUEST FORM
Date of Request:
Utility Name:
Primary Mailing Address:
City: State: County:
PWS ID#:
NPDES ID#:
Utility Type:(water/wastewater)
Utility Size: (Popu
lation Served)
# of Full time Employee's:
# of Front Line Employees Currently
Working:
Utility Contact:
Phone:
Email:
Date Issued:
Quantity of Masks Issued:
Signature of Person Issuing Masks:
Signature of Pe
rson Receiving Masks:
FEMA, working with EPA along with several associations, have identified the following item(s): Reusable Cloth
Masks to distribute to public water utilities during the COVID 19 Pandemic. FEMA has chosen INWARN to
coordinate distribution and tracking of the masks to Indiana Utilities. Many masks have already been
distributed. If your utility would like to request initial delivery of masks, or delivery of additional masks, please
email to the INWARN contact, Jaimie Foreman, jforeman@carmel.in.gov. MAKE SURE TO PUT 'INWARN
FACE MASK' IN EMAIL SUBJECT LINE. Dates and times for distribution/delivery will be arranged once this
information is acquired. If requesting for water and wastewater, please fill out a form for each.
IMPORTANT: You do not have to be an INWARN member to receive supplies. ANY Water or Wastewater
Utility may request masks. Masks will be distributed first come first serve basis. Quantities provided for your
utility will be based on information below and provided FEMA formulas.
(Below only to be filled out upon delivery)
Email Request Form to:
jforeman@carmel.in.gov; Place 'INWARN FACE MASK' in email subject line
(street address)
Signature of Utility Rep: Date:
(Electronic signature is acceptable)
click to sign
signature
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